Digestive diseases affect 1 in 5 Americans annually – at least 60 million people in the United States each year. Digestive diseases account for approximately 50 million physician visits, nearly 25 million endoscopic diagnostic procedures and over 20 million gastrointestinal specimens directed to pathologists – representing $87 billion in direct medical costs attributable to gastrointestinal disease. The demand for gastroenterology care and diagnostic procedures continue to increase, driven by an increasing incidence of gastrointestinal disease and the need for colorectal cancer screening in the aging U.S. population. By 2010, gastroenterologists will perform at least 40 million endoscopic procedures annually, translating into $40 billion endoscopy and $12 billion related gastrointestinal pathology expenses annually in the U.S.

With less than 400 fellowship-trained gastrointestinal pathologists in practice in the United States, approximately 8% of the 20+ million gastrointestinal biopsies currently performed each year are reviewed by pathologists with fellowship training in digestive health and disease. The remaining 90 to 92% of biopsies are reviewed by highly skilled general surgical pathologists including some who have special interest in gastrointestinal pathology.

General surgical pathologists who practice with a focus in gastrointestinal pathology may attend continuing medical education courses offered by fellowship-trained academic and private practice gastrointestinal pathologists, may attend intensive "mini-fellowships" that are offered by select institutions (i.e. AFIP) to further hone their diagnostic skills and develop close working relationships with gastroenterologists to ensure a broad knowledge base with regards to clinical correlation of the findings under the microscope.

Whether a fellowship trained gastrointestinal pathologist, a general surgical pathologist with subspecialty interest in GI or an adept general surgical pathologist is reviewing a particular biopsy or surgical specimen, it is important to keep in mind that the training for the specialty of surgical pathology is rigorous. Following completion of both college and medical school, the surgical pathologist must have also completed an accredited residency in pathology and is board certified in Anatomic Pathology by the American Board of Pathology. Residency in pathology is one of the longest postgraduate training programs, encompassing 4–5 years. (In comparison, internal medicine and pediatrics are only 3 years.)

In most instances, gastrointestinal biopsies and surgical specimens represent common diseases that display common histomorphologic patterns, and are accurately evaluated and classified by adept general pathologists. Similar to many aspects of medicine, not all gastrointestinal tissue specimens require sub-specialist review for the accurate diagnosis to be rendered. Internal medicine physicians treat many gastrointestinal conditions without referral to a gastroenterologist specialist. Similarly, many gastrointestinal tissue biopsies and surgical specimens are accurately diagnosed without referral to a gastrointestinal pathologist. Certain diseases are histologically subtle or the differential diagnosis is complicated or complex. In such cases a close working relationship between the pathologist and gastroenterologist with correlation of clinical, endoscopic, and biopsy findings may be of great benefit to the submitting physician and to the patient.

Appropriate biopsy classification of GI biopsies is critical. Current literature and other non-published reviews estimate that at least 10% of the diagnoses of Barrett’s esophagus, a precancerous condition, are rendered in error. At least 15 – 20% of stomach biopsies have misclassified disease characteristics, 15% of colon polyps are misdiagnosed, and up to 50% of all cases of chronic inflammatory bowel disease are misdiagnosed or misclassified.

Though pathology diagnosis is a critical determinant of future cancer risk and screening interval, many of these diagnoses do not result in significant morbidity or mortality for patients; thus, errors may be "masked" by the limited effect to the patient in the present context.

The economic cost of inaccurate pathology diagnoses can be measured from the perspective of the healthcare system, the gastroenterologist practice and the patient. Within the healthcare system, gastroenterology pathology diagnostic inaccuracy of 10% is equivalent to 2 million misdiagnoses each year. The vast majority of these patients will incur additional medical expenses from repeat clinician office visits; repeat diagnostic procedures, unnecessary enrollment in surveillance programs, and treatment with incorrect or completely unnecessary medications. The cost savings of the correct gastrointestinal pathology diagnosis being rendered at first opportunity by expert board certified surgical pathologists is conservatively estimated within the range of $200M – $1B.

Born out of increasing awareness of subspecialty gastrointestinal pathology services, increased marketing efforts by gastrointestinal pathology companies and increased patient awareness of laboratory errors, there is an increasing trend toward referral of tissue specimens to surgical pathologists with special interest in gastrointestinal pathology.

Media Contact
Jessica Watson
Managing Editor
Clinical Gastroenterology Journal.